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Research Briefs

Uncomfortable Arithmetic - Whom to Cover Versus What to Cover

“Much of the current debate about expanding health insurance coverage avoids addressing an uncomfortable trade-off,” write Harvard Kennedy School’s Amitabh Chandra and co-author Katherine Baicker of the Harvard School of Public Health. With a fixed budget, making benefits more generous means covering fewer people. The same goes for type of service provided: The number of quality-adjusted life-years gained decreases sharply the less cost-effective the services that are covered.

“Designing insurance benefits that are limited to coverage of higher-value care but are extended to more people will generate greater improvements in health than providing unlimited care for fewer people. Policymakers and patient advocates are reluctant to acknowledge that in a world of scarce resources it will not be enough to eliminate waste: we will have to make active choices in our public insurance programs between increasing the number of people covered and increasing the generosity of that coverage.”

“It is clear that some resource-rich countries do surprisingly poorly economically, while others do well. We have noted examples of both sorts: countries such as Norway, Botswana, and Chile that have done very well with their endowments (oil, diamonds, and copper, respectively) versus others such as Nigeria, Bolivia, and Congo that have done poorly. The ‘Natural Resource Curse’ should not be interpreted as a rule that resource-rich countries are doomed to failure. The question is what policies to adopt to increase the chances of prospering. It is safe to say that destruction or renunciation of resource endowments, to avoid dangers such as the corruption of leaders, will not be one of these policies. Even if such a drastic action would on average leave the country better off, which seems unlikely, who would be the policymaker to whom one would deliver such advice?”

“No major policy change has ever occurred without first getting the politics right,” writes Elaine Kamarck, Harvard Kennedy School lecturer. And the politics around legislation aimed at addressing climate change and reducing greenhouse gases is particularly tricky. During debate over a cap-and-trade system, nobody seemed to want — or be able to accurately represent what the system would cost Americans, yet any meaningful solution to climate change will increase the cost of traditional sources of energy. Kamarck argues that the conventional wisdom about the much-maligned carbon tax has to be rethought. A carbon tax would be predictable and straightforward. Its cost to households could be directly offset (by payroll tax deductions, for example). And it would provide an easier path to a global architecture than cap and trade. “Given the urgency of the problem, those who desire immediate action on global warming need to have a ‘Plan B,’” Kamarck concludes.

Why are some civic associations more effective than others? That’s the starting point for a new investigation into leadership by Harvard Kennedy School’s Marshall Ganz. Ganz and his coauthors approached the question by looking at surveys of local groups of the Sierra Club. “To develop our framework for studying effectiveness in civic associations,” they wrote, “we looked to work by organizational scholars who study effectiveness in service-providing and goods-producing organizations and to social movement scholars – and others who study civic associations including social movement organizations . . . . Through this process we developed and articulated a three-tiered conception of effectiveness that sees civic associations as ‘schools of democracy’— places where individuals learn through interaction the skills of democratic practice to pursue collective purpose. From this perspective, the accomplishment of leader development, member engagement, and public recognition are each equally important dimensions for evaluating the effectiveness of civic associations.”

Marshall Ganz Leadership, Membership, and Voice: Civic Associations That Work